Maternal health care in vietnam demand for antenatal care and choice of delivery care services

UNIVERSITY OF ECONOMICS

ERAMUS UNIVERSITY ROTTERDAM

HO CHI MINH CITY

INSTITUTE OF SOCIAL STUDIES

VIETNAM

THE NETHERLANDS

VIETNAM - NETHERLANDS
PROGRAMME FOR M.A IN DEVELOPMENT ECONOMICS

MATERNAL HEALTH CARE IN VIETNAM: DEMAND FOR
ANTENATAL CARE AND CHOICE OF DELIVERY CARE
SERVICES

By Nguyen Thi Hoai Trang

A Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of
Master of Art in Development Economics

Academic Supervisor: Dr. Truong Dang Thuy

HO CHI MINH CITY, June 2016
1


DECLARATION

“This is to certify that this thesis entitled “MATERNAL HEALTH CARE IN VIETNAM:
DEMAND FOR ANTENATAL CARE AND CHOICE OF DELIVERY CARE SERVICES”,
which is submitted by me in fulfillment of the requirements for the degree of Master of Art in
Development Economics to the Vietnam – The Netherlands Programme (VNP). The thesis
constitutes only my original work and due supervision and acknowledgement have been made in
the text to all materials used.
HCMC, June 06th, 2016

Nguyen Thi Hoai Trang

i


ACKNOWLEDGEMENT
I would like to acknowledge my supervisor, Dr. Truong Dang Thuy for his great
contribution to my thesis. Without his support, my thesis would be not possible. By his large
knowledge and experiences, he gave me the informative comments and enabled me to understand
my work better. I would like to express my sincere gratitude to his guidance and encouragement,
which make me stronger to overcome the challenges and fulfill my work completely.
By this chance, I would like to express my appreciation toward all lecturers of the Vietnam
– Netherlands Program who have provided with valuable economic knowledge during my study
in this program. Next, I wish to thank to all my friends here at VNP- MDE 19, who share
unforgettable memories in studying together.
Finally, I would like to express my deep gratitude to my family for their support and
endurance when I pursue my postgraduate studies.

ii


ABSTRACT

This thesis research aims to analyze the impact of individual characteristics, household
characteristic and communities in utilization of maternal health care services in Vietnam. Using
the latest data of Vietnam’s Multiple Indicator Cluster Survey 2013-2014, it employs the Negative
Nominal Model for demand of prenatal care visits and Multinomial Logistic Model for the choice
of delivery facility. With respect to the demand of prenatal care visits, the result shows that higher
education, higher age, exposure to mass media and no religion increase the number of prenatal
care visits while higher birth order, unmarried or separated status, ethnicity group and lower
household wealth index decrease the number of prenatal care. Moreover, living in rural,
disadvantaged areas and the community with higher illiteracy rate decrease the demand of prenatal
care visits while living in the community with higher proportion of women giving birth at health
facilities increase the demand. Concerning the choice of delivery facility, more prenatal care visits
and exposure to mass media are positively associated with the choice of giving birth at public
hospital. In contrast, suffering the burden of taking care more children, lower household wealth
index, living in rural and the community with higher illiteracy ratio adversely affect the choice of
public hospital delivery. The results suggest the improvement of maternal health program in rural
and underdeveloped areas as well as universal education over the country, especially for the ethnic
minority group.

Keywords: prenatal care visits, the place of childbirth, individual characteristics, household
characteristics, community characteristics, Vietnam.

iii


Contents
DECLARATION ............................................................................................................................. i
ACKNOWLEDGEMENT .............................................................................................................. ii
ABSTRACT ................................................................................................................................... iii
LIST of TABLES and FIGURES ................................................................................................. vii
ABBREVIATION........................................................................................................................ viii

CHAPTER I .................................................................................................................................... 1
INTRODUCTION .......................................................................................................................... 1
1.1 Problem statement .............................................................................................................. 1
1.2 Research objectives ............................................................................................................. 3
1.3

Research questions ......................................................................................................... 4

1.4

Structure ......................................................................................................................... 4

CHAPTER II................................................................................................................................... 5
LITERATURE REVIEW ............................................................................................................... 5
2.1 The role of maternity health care ...................................................................................... 5
2.2 Overview of maternal health and health care in Vietnam .......................................... 6
2.2.1 The culture.................................................................................................................... 6
2.2.2 The two-child policy ..................................................................................................... 6
2.2.3 Maternal mortality ratio and maternal health care in Vietnam ............................. 7
2.3 The demand for health care ............................................................................................. 11
2.3.1 Theoretical background ............................................................................................ 11
2.3.2 Empirical Literature Review .................................................................................... 13
2.4 The choice of health care provider .................................................................................. 19
2.4.1 Theoretical background: ........................................................................................... 19

iv


2.4.2 Empirical literature review ....................................................................................... 20
CHAPTER III ............................................................................................................................... 23

METHODOLOGY AND DATA DESCRIPTION ....................................................................... 23
3.1 Conceptual framework ..................................................................................................... 24
3.2 Empirical framework ....................................................................................................... 25
3.2.1 Demand for Prenatal care ......................................................................................... 26
3.2.2 Choice of birth delivery facility ............................................................................... 27
3.3 Data .................................................................................................................................... 28
3.4 Variables definition........................................................................................................... 28
3.4.1 Dependent variables................................................................................................... 28
3.4.2 Independent variables ............................................................................................... 29
RESULTS AND DISCUSSIONS ................................................................................................. 31
4.1 Descriptive Results ............................................................................................................ 32
4.2 Analysis of Demand for prenatal care ............................................................................ 34
4.2.1 Bivariate analysis ....................................................................................................... 34
4.2.2 Analysis of Negative Binomial Model ...................................................................... 37
4.3 Analysis of Choice in the delivery care providers .......................................................... 41
4.3.1 Bivariate analysis ....................................................................................................... 41
4.3.2 Analysis of Multinomial Logistic Model .................................................................. 44
CHAPTER V ................................................................................................................................ 47
CONCLUSION, RECOMMENDATION and LIMITATION ..................................................... 48
5.1

Main findings ................................................................................................................ 48

5.2

Policy Recommendation .............................................................................................. 49

5.3

Limitation and Further Research ............................................................................... 50

v


REFERENCE ................................................................................................................................ 51
APPENDIX ................................................................................................................................... 56
STATA RESULTS ....................................................................................................................... 71

vi


LIST of TABLES and FIGURES
List of Tables
Table 1: Description of Variables ................................................................................................. 30
Table 2:Descriptive Results – Numeric Variables ........................................................................ 33
Table 3 : Descriptive Results - Dummy Variables ....................................................................... 33
Table 4: Bivariate analysis in the demand of prenatal care visits ................................................. 35
Table 5: Negative binomial regression for the demand of prenatal care visits ............................ 40
Table 6 : Bivariate analysis in the choice of delivery care providers - numeric independent
variables ........................................................................................................................................ 41
Table 7:Bivariate analysis in the choice of delivery care provider – dummy independent variables
....................................................................................................................................................... 43
Table 8: Multinomial Logistic Regression for the choice of delivery care provider .................... 46
Table 9: Marginal effects for the choice of delivery care provider .............................................. 47

List of Figures
Figure 1: MMR in Vietnam in the period of 2000 – 2015 .............................................................. 8
Figure 2: MMR of the Asian countries in the period of 2000 – 2015 ............................................ 8
Figure 3: Percentage of women having at least 1 visit and at least 4 visits during pregnancy ....... 9
Figure 4: The percentage of the women taking antenatal care visits by residence in 2011 and 2014

....................................................................................................................................................... 10
Figure 5: The percentage of the women taking antenatal care visits by ethnicity in 2011 and 2014
....................................................................................................................................................... 10
Figure 6 The association between individual level, household level and community level
characteristics with the utilization of maternal health care services ............................................. 25
Figure 7: The association between the demand of maternal care visits and numerical independent
variables ........................................................................................................................................ 37

vii


ABBREVIATION
ANC

Antenatal Care

CSDH

Commission on Social Determinants on Heath

GSO

General Statistics Office

IMR

Infant Mortality Ratio

MDGs

Millennium Development Goals

MICS

Multiple indicator cluster survey

MMR

Maternal Mortality Ratio

WHO

World Health Organization

viii


CHAPTER I
INTRODUCTION
1.1 Problem statement
There is a growing concern about the maternal health care globally, especially in low
income countries. World Health Organization (WHO 2014) reported that the global maternal
mortality ratio (MMR) in 2013 was 210 maternal deaths per 100 000 live births, decreasing
from 380 maternal deaths per 100 000 live births in 1990. However, the ratio in developing
regions was 14 times higher than in developed regions. Even though maternal death is generally
decreasing worldwide, it has yet to achieve the target of Millennium Development Goal 5 by
reducing the MMR by three quarters between 1990 and 2015 (WHO 2014).
The maternal death has direct causes and indirect causes. The direct cause results from
arising complications during pregnancy, delivery and postpartum, or improper treatment such
as hemorrhage, infection, obstructed labor, unsafe abortion, ectopic pregnancy and anesthesiarelated deaths while the indirect cause results from the disease which previously exists or be

not due to indirect obstetric causes like hepatitis anemia, malaria, heart disease and tetanus
(WHO 2005). It was reported that direct causes made up the higher number of maternal death
than indirect causes with 80% of the total MMR (WHO 2005).
These complications could be preventable thanks to the intervention of health care such
as antenatal care and delivery care, which was introduced by WHO in the safe motherhood
package in 1994 (Tran 2012). Antenatal cares provide the opportunities to pregnancy women
and their family to be informed of their health and the growth status of unborn baby. Low birth
weights could be prevented if the pregnant women are well acknowledged about their unborn
baby’s weight and height during the antenatal care and then improve their diet. In addition,
antenatal check-ups detect the danger signs and risks of pregnancy and delivery and make
timely interventions. For example, tetanus immunization in the antenatal care period is vital to
save the life of the women and their baby. The management of high blood pressure during
pregnancy ensures the maternal health and increase the infant survival (WHO and UNICEF
2003). Furthermore, delivery care also plays an important role in reducing maternal deaths.
WHO recommended the child birth at health facility or attended by skilled health staffs to
ensure to the safe delivery and give birth to healthy baby. With good hygiene and adequate
medical equipment, the delivery at facility could decrease the complications arising from the

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labor such as hemorrhage, obstructed labor. In addition, skill health professionals are available
in the facilities ensure safe delivery and provide proper emergency management. (Tran 2012)
In pursuit of Millennium Development Goal 5 “Improving maternal health”, Vietnam
also is making progress in improving the maternal health with the drop of maternal mortality
ratio. The World Bank shows that MMR in Vietnam has remarkable improvements in last 15
years in decrease from 81 deaths per 100,000 live births in 2000 to 54 per 100,000 in 2015.
The access to antenatal care, an important period for health of pregnant women and their baby
and delivery service has also increased. Multiple indicator cluster survey in 2014 (MICS 5)
shows that the percentage of women aged 15-49 with a live birth in the last two years who

received antenatal care at least once is 95.8 per cent nationwide. However, there are
considerable disparity in maternal mortality ratio and utilization of maternal health care among
ethnicity group, place of residence and the regions where the pregnant women are living. MPI
2015 reported that maternal mortality in mountainous areas is more than three times higher
than in lowland areas. Furthermore, MICS5 indicates that the times of prenatal care visits
differs among the women living rural and urban area, especially regarding having more than 4
visits. In addition, the ethnic minority groups get more disadvantage of access to maternal
health care with 79% of those having 1 visit and 32.7% of those having at least 4 visits
compared to 99.2% and 82.1 % of the Kinh group as shown. Therefore, growing disparities in
health outcomes and health care utilization have posed a great challenging in recent years.
The above challenges lead to several studies in the utilization of maternal health care
in Vietnam. Most of them focused on the influence of demographic and socioeconomic factors
(Sepheri et al. 2008, Tran et al. 2011, Goland et al. 2012, Malqvist et al. 2012, Malqvist et al.
2013). Demographic factors which were shown to increase the probability of the health services
are younger age, low birth order while the factors reported to decrease the probability are
separated or unmarried status, unintended pregnancy. In addition, socio-economic factors make
greater influence on the use of the maternal health care services. Higher education level of a
woman is the most important determinant reported in the previous studies (Sepheri et al. 2008,
Tran et al. 2011, Goland et al. 2012, Malqvist et al. 2012, Malqvist et al. 2013, Wakabayashi
2014). Lower household income is also shown to be a strong factor in the likelihood of using
maternal health care (Sepheri et al. 2008, Goland et al. 2012). Some studies emphasized the
disparity in the maternal health care utilization among ethnic majority and minority groups
(Malqvist et al. 2012, Malqvist et al. 2013). On the other hand, major equity in rural and urban

2


areas also was identified by Tran et al. (2011) and Sepheri et al. (2008) pointed out the regional
disparity in the availability and accessibility to the maternal health care in Vietnam.
However, most of them overlooked the community factors, except Sepheri et al. (2008)

estimating the impacts of poverty rate. The omission of the factor may bias the influence on
maternity health care utilization, especially for the disadvantaged women. The omission of
community effects may result in biased estimates of the roles of factors (Singh et al. 2014).
Community beliefs and norms encourage or prevent health care seeking behaviors of the
women. In addition, community economic development may influence the access to health
services and indirectly increase decision making power of women and positive attitudes toward
health service use. (Stephenson et al. 2006). The community level factors reported to be strong
indicators could be the poverty rate, the proportion of women in the community with higher
education and the proportion of women delivering their child in health facility. The poverty
rate was negatively associated with the probability of taking antenatal care (Gage & Calixte
2006, Sepehri et al. 2008, Ononokpono et al. 2013, Singh et al. 2014,) and facility delivery
(Gage & Calixte 2006, Sepehri et al. 2008) whereas the high proportion of women with higher
education and higher proportion of women choosing facility for delivery were positively
associated with the utilization of maternal health care (Stephenson et al. 2006, Gage 2007,
Ononokpono et al. 2013, Singh et al. 2014).
Therefore, there is a need to properly investigate the determinants on health care service
utilization including individual level, household level and community level characteristics.
Using the latest dataset from Vietnam Multiple indicator cluster survey in 2014 (MICS 5), this
study applies the Poisson Model to estimate the impact of social determinants on the demand
for prenatal care visits, and the Multinomial Logistic Model to measure the association between
social factors and choice on delivery care providers.
1.2 Research objectives
The overall objective of this thesis research is twofold. First, we analyze the demand of prenatal
health care. Particularly, we examine the determinants of the number of antenatal care visits of
women taking during the last two years using data from MICS 5. Second, we investigate the
choice on service facility for delivery of pregnant women in Vietnam.

3

1.3 Research questions
To investigate the above objectives, the following questions need to be answered thoroughly:
Question 1: What are the determinants of the demand for antenatal care visits?
Question 2: What are the determinants of the choice on delivery care provider?

1.4 Structure
The paper is organized as follows. In Chapter 2, the general theories related to the
demand of health care and the choice of health care provider are discussed and the previous
studies on the impact of social determinants on utilization of maternal health care are reviewed.
Chapter 2 presents the conceptual framework and the methodology with two applied methods
using the dataset namely Multiple Indicator Cluster Survey 2013-2014 (MICS5). In the same
chapter, methods investigating the determinants of the demand of prenatal health care and the
choice of service facility for delivery will be presented. The results and discussion are presented
Chapter 4. Chapter 5 concludes the paper and discusses policy implications.

4


CHAPTER II
LITERATURE REVIEW
This chapter presents the theoretical review and empirical review regarding the demand
for prenatal care visits and the choice of facility for delivery. The first part is to provide the
role of maternal health care and the overview of maternal health care in Vietnam. The next part
is to present the theoretical background for the demand for health care services, and the choice
of health care facility and their determinants. The final section reviews the determinants
affecting the demand of prenatal care visits and the choice of delivery care providers reported
in the previous studies in developed countries and developing countries, especially in Vietnam.
2.1 The role of maternity health care
Motherhood is a positive experience which a women encounters; however, there are
some health problems happening during pregnancy, childbirth, and the postpartum period. The

consequences impact seriously not only on the women’s health but also on the babies. Three
quarter of maternal deaths is reported to occur during childbirth and the postpartum period.
However, antenatal care and delivery care can prevent these complications.
The introduction of antenatal care (ANC) began in the early 1900s with the aim of
helping pregnant women and the unborn healthy and detecting adverse conditions in order to
take timely interventions. For example, the antenatal care will enable the women to enhance
the understanding of the fetal growth and her health status. Adverse outcome such as low birth
weights can be avoidable by improving the women’s nutritional status. In addition, the women
will be informed about the risks during pregnancy and delivery. The World Health
Organization (WHO) recommended at least one visits to skilled health providers or at least four
ANC visits to any providers. According to the guidelines of WHO, the ANC program includes
assessment of mother and fetus like body weight and height measurement, blood pressure, urine
and blood tests; medical provisions like tetanus vaccination and supplement of iron and foliate
and health consulting and education.
The delivery at health facilities also plays an important role to ensure women to go
through childbirth safely and deliver healthy infants. In fact, proper medical technology and
hygienic conditions during delivery can prevent complications and infections leading to
morbidity and mortality of mother and her child. In addition, skilled birth attendants are
available in most health facilities. According to WHO, a skilled birth attendant is defined as a
midwife, doctor or nurse, who is well skilled to ensure normal childbirth and the postnatal
5


mediation, and who can detect complications and provide necessary emergency management.
WHO recommended that in countries with very high MMR, at least 60% of child deliveries
should be assisted by skilled birth attendants by 2015. During 2005-2010, it was reported that
69% of women giving birth were attended by skilled birth staffs. (Tran, 2012)
2.2 Overview of maternal health and health care in Vietnam
2.2.1 The culture
Vietnam culture is highly influenced by Confucianism, especially in the north region

of the country. According to the tradition of Confucianism, the son of the family will inherit
the family resources and worship the ancestors. In addition, he has responsibility for taking
care of the family members and maintains the continuity of the family line. Therefore, giving
birth to a son brings a proud to the family and improves the status of the women in the family.
However, it will put high pressure of having a son on the women in the family, especially for
the women with daughters. The strong preference for sons is the main reason for increasing sex
ratio at birth.
Moreover, male members are considered as the breadwinners and main income earners
in the family and have strong decisions on the family affairs whereas female members are
considered as vulnerable members when their life is determined by her parents. After getting
married, they will usually live with their husband family and the income will probably be
controlled by the parent-in-law and their husband. The strong Confucianism and existing
hierarchism limits their autonomy and their independent decisions for their lives, especially
their health. For example, the childbirth experience from the mother and the mother-in-law
highly influence on the maternity care of young women and could prevent the women to seek
essential maternal health care.
2.2.2 The two-child policy
The two-child policy in Vietnam was issued in late 1980s with restriction of the
maximum number of children per household. Vietnam government practiced some family
planning measures to reach the goal such as providing the free birth control devices as well as
prosing the facilities for those who was allowed for abortions. In addition, the family who did
not comply with the two-child policy, they would be penalized in different ways like paying
high fee. For the government staffs who broke the policy, they would be prolonged the salary
raise or reducing to lower position. Therefore, due to fear of penalization and discredit, some
women conceal their pregnancy and do not take adequacy of maternal health cares. In addition,
6


more children put heavy burden on shoulders of women and create time and financial
constraints to utilization of maternal health care services. After many revision of the policy,

the revised 2009 Population Ordinance is the effective prevailing policy in Vietnam. According
to the Ordinance, couples have right to decide the time of having children and the birth spacing
but are allowed to have one or two children. Thanks to the population policy, the total fertility
rate dropped from 2.55 in 2001 to 1.99 in 2011 (GSO 2013) suggesting the two-child policy
was successful to ensure the steady population growth. However, there are some challenges for
the government to take account for. The contraceptive methods had been not conducted
effectively. IUD is the most popular method applied in most families; however, it comes with
the side effects so many women hesitate to use it. In addition, Vietnam has faced the high
abortion rate, especially among the young age. It could be mainly attributed to lack of
knowledge about the contraceptive methods and son preferences beside other reasons such as
financial problems or health status.
2.2.3 Maternal mortality ratio and maternal health care in Vietnam
In Vietnam, the government recommends pregnant women should have at least three
prenatal visits during the pregnancy to detect and prevent the risks negatively affecting the
health of mother and baby. The content of prenatal care includes blood pressure measurement,
urine testing, blood testing and measure of weight and height. In addition, the national
guidelines suggest that pregnant women should deliver the baby at health facilities. Proper
medical attention and hygienic condition at health facilities reduce the complications occurring
in and after the childbirth. In addition, for the complications, Caesarean section is required but
should be performed by the skilled obstetric doctors to ensure safe childbirth. During the
postpartum period the guidelines recommend at least two health checkups for both mother and
child.
The maternal mortality ratio is the ratio of women who die from causes related to
pregnancy and childbirth in the period from pregnancy until 42 days after delivery, per 100,000
children born during the study period. The data from the World Bank shows that MMR in
Vietnam has remarkable improvements in last 15 years in decrease from 81 /100,000 in 2000
to 54/100,000 in 2015. The target of Millennium Development Goal 5 with MMR of 58.3 per
100,000 live births by 2015 has been achieved completely. However, when comparing to other
Asian countries, Vietnam still left behind the developed countries such as Singapore, Malaysia

7


and Thailand. Therefore, Vietnam should make greater effort to reduce the MMR and ensure
the persistent population growth.

Maternal mortality ratio (per 100,000 live
births)
81

76

72

68

64

61

59

58

58

57

58

56

56

55

54

54

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Figure 1: MMR in Vietnam in the period of 2000 – 2015
Source: The World Bank

600

500

Lao PDR

Malaysia
400

Indonesia
Thailand

300

Cambodia

Brunei Darussalam

200

Singapore
Myanmar

100

Philippines
Vietnam

0

Figure 2: MMR of the Asian countries in the period of 2000 – 2015
8


Source: The World Bank
In order to reduce MMR and IMR, WHO recommends each pregnant woman should
have at least four prenatal care visits or at least one prenatal care attended by professional health
staffs. It is widely agreed that antenatal care is vital to provide the information to women and
her families about potential risks during pregnancy and childbirth. Vietnam has made
significant improvements in antenatal care coverage over the last years. The figure 3 shows
that 95.8 % of pregnant women have at least 1 prenatal care visits in 2014, which is higher than
the ratio in 19997. However, the percentage of those receiving more than 4 visits is still low at
73.7%. This is a challenge against which the country should take more measures. In addition,
there are considerable disparity in utilization of maternal health care among ethnicity group,
place of residence and the region where the pregnant women are living. Figure 4 indicates that
there is greater difference in the times of prenatal care visits among the women living rural and

urban area, especially regarding having more than 4 visits. In addition, the ethnic minority
group get more disadvantage of access to maternal health care with 79% of those having 1 visit
and 32.7% of those having at least 4 visits compared to 99.2% and 82.1 % of the Kinh group
as shown in Figure 5.

At least 4 times by any providers

At least 1 visit by skilled health worker

90,8

86,4
70,6

95,8

93,7
73,7

68,3

29
15

1997

2000

2002

2006

2011

2014

Figure 3: Percentage of women having at least 1 visit and at least 4 visits during
pregnancy
Source: Ministry of Planning and Investment, MICS4

9


Antenatal care visits by residence
Urban
97,90

99,10

92,00

Rural

94,40

86,30

81,60

68,50

50,50

2011

2014

2011

1 visit

2014
At least 4 visit

Figure 4: The percentage of the women taking antenatal care visits by residence in 2011
and 2014
Sources: MICS3 and MICS4

Antenatal care visits by ethinicity
Kinh

Non Kinh

99,20

97,90

82,10

79,00

73,20

67,00

32,70
21,00

2011

2014
1 visit

2011

2014
At least 4 visit

Figure 5: The percentage of the women taking antenatal care visits by ethnicity in 2011
and 2014
Sources: MICS3 and MICS4

10


2.3 The demand for health care
2.3.1 Theoretical background
Economists became interested in the health seeking behavior in the late 1960s and
investigating the factors influencing the behavior. The major contributions were by Grossman
(1972), Rosenstock (1974), Thaddeus and Maine (1994) and Andersen (1995).
Grossman (1972) argued that what individual demand when purchasing health care is

not health care but good health. Firstly, he set up the model of demand for health, in which the
individual has positive utility of consumption goods and negative utility of sick time 𝑡 𝑠 (𝐻).
(Zweifel et al. 2009)
𝑈 = 𝑈(𝑡 𝑠 (𝐻0 ), 𝑋0 ) + 𝛽𝑈(𝑡 𝑠 (𝐻1 ), 𝑋1 )

(1.1)

In addition, the health stock H changes overtime. Therefore, the health capital
decrease at the rate 𝛿. However, the individual can increase health capital by investing in I. In
a two-period model, the current health could be specified as
𝐻1 = 𝐻0 (1 − 𝛿) + 𝐼(𝑀, 𝑡 𝐼 )

(1.2)

Where, U is utility, H is stock of health capital, 𝛿 is the rate of the depreciation of the
heath stock, w is wage rate, X is consumption goods, M is the consumed amount of medical
services, I is investment in health, 𝑡 𝑠 is sick time and 𝑡 𝐼 is time invested in favor of health.
Grossman (1972) argued that the individual demand for health for two reasons: first, as
investment commodity and second, consumption commodity.
Basing on the function 𝐼(𝑀, 𝑡 𝐼 ) and 𝑡 𝑠 (𝐻1 ) from (1.1) and (1.2), Grossman constructed
the demand function for medical services in investment model:
ln 𝑀 = 𝑐𝑜𝑛𝑠𝑡. − (1 + 𝛼𝑀 (𝜀 − 1))𝑙𝑛𝑝 + (1 + 𝛼𝑀 (𝜀 − 1))𝑙𝑛𝑤 − (1 − 𝜀)𝛼𝐸 𝐸

(1.3)

Where, 𝛼𝑀 is the production elasticity of medical services and 𝛼𝐸 is the effectiveness
of education E; 𝜀 is the marginal efficiency of health capital 𝐻1 .
From the utility function (1.1) including sick time and consumption good, he
constructed the demand function for medical services in consumption model:
ln 𝑀 = 𝑐𝑜𝑛𝑠𝑡. − (1 + 𝛼𝑀 (𝜅 − 1))𝑙𝑛𝑝 + (1 − 𝜅)(1 − 𝛼𝑀 )𝑙𝑛𝑤 − (1 − 𝜅)𝛼𝐸 𝐸 −

𝜅𝑙𝑛𝜆
(1.4)

11


From the investment model (1.3) and consumption model (1.4), the demand of health
services depends on the price of medical services, the wage rate, education and wealth. It could
be seen that the price of medical services decrease the optimum quantity of 𝐻1 whereas the
wage rate increase the quantity of 𝐻1 . In the multiple period model, both of demand functions
also are added the age because the depreciation rate 𝛿 is positively correlated with age. (Zweifel
et al. 2009)
In addition to the Grossman Model, some researches brought out some model to explain
the individual’s health seeking behavior. Rosenstock (1974) introduced health belief model to
explain the health-related behavior. The model suggested that individual’s belief about health
problem, perception regarding benefit and barrier and cues to action combine together to
explain the health-promoting behavior. The modifying variables such as demographic and
psychosocial characteristics made the indirect effect on the perceptions. In the model, the
perception regarding serious consequences and risks from developing a health problem most
highly increase the likelihood of engaging in health-promoting behaviors. The next step was
the perception of benefits received from taking action and barriers to taking action such as
inconvenience, side effect. If the perceived benefits outweigh the barrier, it leads to healthpromoting behavior or otherwise. The following is cues to action including internal and
external cues. Internal cues are pain, symptoms while external cues are information obtained
from friends, mass media. The model was applied to develop intervention to change healthrelated behavior by targeting the parts in the model.
Thaddeus and Maine (1994) developed the three delay theory to identify the barriers to
the timely and adequately utilization of maternal health care. They viewed that the first phase
was delay in seeking care. The factors effecting the phase included decisions of individual and
family, the status of women, previous experience regarding health care system, financial and
opportunity cost. The next phase was delay in getting access to the health facility due to the
availability of facilities, distance to facilities, transportation cost and transportation

infrastructure. The last phase was delay in taking adequate care. The relevant causes were lack
of equipment and skilled health staffs, qualification of health staffs.
The behavioral Model of Health Services Utilization by Andersen (1995) has been used
in the studies on utilization of health services in both developed and developing countries
(Thind et al. 2008). In the Andersen’s Model, one individual getting access to and using health
care services was a function of three factors, namely predisposing, enabling and need factors.
The predisposing factors were classified into three groups such as demographic characteristics,
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social structure and health beliefs. Demographic characteristics represent the tendency of
individuals to use services, including age, gender, marital status while social structure reflect
the ability of individuals to seek health care services, including education, occupation and
ethnicity. Health beliefs were perception and attitudes regarding the health care systems that
influence the utilization of the services. The next was enabling factors, both personal and
organizational, which measure the actual ability to obtain health services. Personal enabling
factors included income, health insurance, travel and waiting times while organizational
enabling factors were the availability of health facilities. The last one is need factors, the direct
causes to utilization of health services. The need was the self-assessment of health status and
evaluation from health staffs.
2.3.2 Empirical Literature Review
Theoretically, prenatal care is considered a vital factor in maternal and infant mortality.
Measuring and counseling during prenatal care help women understanding health status of
herself and her baby, detecting risks in order to ensure safe pregnancy, childbirth as well as
decrease post-partum problems. While some researches were conducted to estimate the
association between maternal health care and health outcome, some studies focus on
determinants effecting utilization of maternal health care. The below is to present the factors
influencing the demand of prenatal care visits and the choice of delivery location from the
previous studies.
The determinants are categorized into three characteristics including individual level,

household level and community level. The individual variables include education attainment,
maternal age, marital status, religion, ethnicity while household characteristics are household
size and household wealth. Further, community level consists of place of residence, region
dummies, poverty rate and illiteracy rate.
Individual level characteristics
Mother’s education
Most studies highlighted the importance of mother education on the use of maternal
health care. The higher level of education women has, the more likely to use adequate ANC.
(Arthur 2012, Bbaale 2011, Navaneetham & Dharmalingam 2002). It was explained that
educated women had more decision-making power on health-related matters and seek the better
health care outside their home (Navaneetham & Dharmalingam 2002). However, there was no
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significant difference in the utilization of maternal health care among educated women by level
of education, especially between primary level and second level. (Navaneetham &
Dharmalingam 2002). In addition, when measuring the effect of the introduction of National
Health Insurance (NHI) in Taiwan, Chen et al. (2003) found that education attainment did not
have insignificant impact on antenatal care before NHI but was significantly positive after NHI.
The reason for this difference was ambiguous. In general, educated women are well informed
of the importance of maternal care and will increase more frequencies of antenatal care visits
than less-educated mothers.
Marital status
Marital status also is a key determinant of the use of maternal health care. Sepehri et al.
(2008) suggested that the marital status impacted the use of any prenatal care greater than the
number of visits but has no significant influence on decision of delivery place. It could be
explained that single mothers unwillingly get access to the health care due to face of
stigmatization because the childbirth is widely considered the responsibility of mother as well
as her husband in Vietnam (Sepehri et al. 2008). Researches in other countries were consistent
with the study of Sepehri et al. (2008). In the study in Taiwan, Chen et al. (2003) found that

thanks to the support from their husband, married women more likely to get access to maternal
care visits than unmarried women.
Mother’s age
The age of expectant mother is other factor in the utilization of maternal health services.
The higher age the mothers get, the lower the probability they will seek health care (Arthur
2012). It could be explained that experience and knowledge related maternal health may
influence on the maternal health seeking behavior (Chen et al. 2003). Tsawe & Susuman (2014)
showed that the women in the age of 15-39 more likely to take health check-ups frequently
than those in the age of above 40. However, there were some researches showing that women’s
age was insignificantly associated with the attendance of ANC for example, in Turkey (Celik
& Hotchkiss 2000).
Birth order

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As the same as the age of expectant mother, most studies found that the increasing
number of children ever born had the same negative effect on the use of maternal health care
services. The higher order births will decrease the likelihood of using the services for some
reasons. It may be due to time and resource constraints for women having larger families.
(Navaneetham & Dharmalingam 2002). In contract, those who have the first pregnancy will
more likely to use the antennal care due to lack of experience. Arthur (2012) argued that those
who underwent the child birth may undertake ANC visits less because she had bad experience
with the service. Similarly, Tsawe & Susuman (2014) agreed with Arthur (2012) that the use
of maternal health care was influenced by the experience over the provided service. If a woman
is provided the better service, she willingly utilizes the service more frequently. On the other
hand, due to the two-child policy and fear of penalties, those with more two children may
undertake less maternal health care (Sepehri et al. 2008).
Unintended pregnancies
Studying in the maternal health service in Southwestern Ethiopia, Wado et al. (2013)

found that pregnancy intention was significantly related to the utilization of antenatal care but
insignificantly to the delivery care. The reason why the unwanted pregnant women less likely
to receive antenatal care adequately is ambiguous. Wado et al. (2013) hypothesized that women
with unwanted pregnancies did not prepare well in the respect of emotion and finance for
childbirth and childbearing so they less take care of their health and their unborn. One of the
argument is the women with unintended pregnancies recognized their pregnancy late so they
miss the first timing antenatal care visits. Wado et al. (2013) observed that women with
unwanted pregnancy detect the pregnancy around one month later compared with ones with
pregnancy intention. In general, the study implied that the pregnancy intention was highly
associated with the utilization of maternal care; however, its association with the delivery care
was still unclear.
Media exposure
Some studies resulted that frequencies of using mass media positively related to the
utilization of ANC. The higher is the level of exposure to mass media like radio and television
the higher is the likelihood of using ANC. Navaneetham & Dharmalingam (2002) found that
women watching television and listening radio regularly increased the opportunities of her
seeking ANC. It can be explained that the mass media will provide the information regarding
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to the maternal health and enhance the awareness of the available maternal health services.
Tsawe & Susuman (2014) reported that those who had more knowledge of the maternal health
service more likely to receive the service timely and adequately. In fact, lack of information
poses the challenges to the utilization of maternal health.
Working status
The importance of working status in maternal health care utilization also is well
documented in some previous studies. Navaneetham & Dharmalingam (2002) found that nonworking women more likely seek maternal health care services than earning women. It could
be explained that non-working women were relatively richer in comparison with those
working. In addition, women’s work in the developing countries does not come with well-paid
salary, which leads lower likelihood of using maternal health care services. Another study by

Bbaale (2011) pointed out that the type of job which pregnancy women related to impacts the
utilization of antennal care in different way. It could be attributed to conditions of jobs and
income they earn, which has great effect on the affordability of health care service. Women
who working in farm or factory have more tendency to use antenatal care than housewives as
well as women who working in government more likely seek antenatal care after being covered
by national health insurance (Chen et al. 2003).
Household-level characteristics
Ethnicity
The significant impact of ethnicity in the utilization of maternal health services is found
in some studies. Sepehri et al. (2008) showed that women belonging to ethnic majority more
likely give birth at health facilities than those in ethnic minority in Vietnam. It could be
explained that ethnic group find difficulties to communicate with health provider due to
language barrier. In addition, lower attainment of maternal health care among ethnic group
women is attributed to lower level of education and poor socio-economic condition (Singh et
al. 2014). In other countries, the results are consistent with this study. Navaneetham &
Dharmalingam (2002) pointed out that women in “Schedules” castes and tribes had lower ANC
check-up in India. Similarly, Kudish women were less likely to take ANC service in Turkey
(Celik & Hotchkiss 2000).

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